The European Cancer Patient Coalition welcomes the opportunity to contribute to discussions
on the Rio + 20 Outcome Document. We recognise that behind the Rio Conference is a
commitment at the highest levels of Member State Governments to focus on areas of society
where policies to promote innovative mechanisms and solutions that could help to generate
increased development and to tackle poverty.

We would encourage the delegates to put a strong emphasis on health, especially on Non-
communicable Diseases. As you are aware, this issue is just barely on the radar screen of
economic policy-makers, who most often do not see that NCDs pose a threat to development,
economic growth and poverty alleviation. Over the next 20 years, NCDs will cost more than
US$ 30 trillion, representing 48% of global GDP in 2010, and pushing millions of people below
the poverty line. For example:

As it will be evidenced by our contribution below: a unified front is needed to turn the tide on
NCDs. Governments, but also civil society and the private sector must commit to the highest
level of engagement in combating these diseases and their rising economic burden. The
economic impact of not dealing with NCDs, in particular cancer would be devastating to
developing economies and health care systems alike.

Therefore, in order to achieve positive economic impact and growth as well as in a number of
other policy areas for developing countries, we advocate that it is essential that the
international community adjust the framework so as to include actions on NCDs in particular
cancer on Rio+20.

Yours Sincerely,

Francesco De Lorenzo
ECPC Vice President
FAVO

ECPC Contribution to Rio + 20 Outcome Document

Overview

i. The current focus of the structure for the future RIO+20 Conference does not take into
account sufficiently the economic burden of health inequalities nor the economies
benefits that can be realized through the establishment of effective health systems so
as to tackle poverty and ill health for future generations. Health impacts several
economic outcomes: wages, hours worked, labour force participation, early retirement,
labour participation of those caring for a ill member of the household, education
outcomes (good health in childhood reduces school absenteeism and early drop-out
rates.

ii. In the area of health, priority should be given to focus on Non Communicable Diseases
(NCD): they are responsible for the majority of disability adjusted life years lost and
therefore threaten the economic viability of developing countries. The World Economic
Forum has identified NCDs as the second most severe threat to the global economy in
terms of likelihood and potential economic loss. Currently, more than 60% of all deaths
worldwide stem from NCDs. Health inequalities have been estimated to cost the EU
around ?141 billion in 2004 or 1.4% of GDP, when taking into account labour
productivity lost and costs to social security. A recent study conducted by the American
Cancer Society estimated the cost of DALYs due to cancer worldwide in 2008 at US$
895 billion (John & Ross, 2010).

iii. An improved management of NCDs would render the biggest positive impact in terms of
increased well-being, economic growth and in a reduction of the economic burden of
non-communicable disease.

iv. The economic impact of not dealing with ill-health would be devastating to developing
economies and health care systems alike. Therefore, in order to achieve positive
economic impact and growth, it is essential that the Rio+20 agenda adjust its framework
so as to address Health and the issue of Non-Communicable Diseases.

v. The most cost effective solution to reduce NCDs are through public health interventions
that take a health prevention approach, which address the determinates of health
(nutrition, alcohol, tobacco, physical activity and the social determinants of health.).
vi. Addressing this imbalance through projects to combat health inequalities, potential
discriminating legislation and attitudes, to raise awareness and improve data collection
should be a strong priority for the inclusion of this in Rio+20 Conference. Furthermore,
by tackling the economic burden of diseases and health inequalities, the Rio+20 could
accomplish much towards achieving the goal of ensuring sustainable health systems
and relieving the economic burden that this has on developing countries.

In the following pages, we have provided suggestions to the questions posed in the Guidance
Document on the ?Inputs for Compilation Document?.

Question 1: What are the expectations for the outcome of Rio+20, and what are the
concrete proposals in this regard, including views on a possible structure of the
Outcome document?

ISSUE 1: REPRESENTATION AND ACCOUNTABILITY FOR A HEALTHY POPULATION

i. While the emergence of the G-20 at the level of heads of states and governments
provide the opportunity for strengthening global economic and financial governance
to a kind of a steering committee of the global economy.

ii. Nevertheless, institutions need to be legitimate and have credible enforcement
power in order for global governance to work. The G-20 seen to be effective, needs
to deliver a good solution to the serious problem of health imbalances in developing
countries. G20 nations represent around 88% of world GDP and 65% of the
population. However, 35% of the world?s population and 80% of countries do
not have a voice around the table.

iii. Additionally, the world population is increasing. The UN projections indicate that
there will be approximately 2 billion more people by 2050. In addition, the share of
those aged 60 and older has begun to increase and is expected to grow very rapidly
in the coming years. Since NCDs disproportionately affect this age group, the
incidence of these diseases can be expected to accelerate in the future. Increasing
prevalence of the key risk factors will also contribute to the urgency, particularly as
globalization and urbanization take greater hold in the developing world.

iv. In the Report by the Secretary General for the Preparatory Committee for the United
Nations Conference on Sustainable Development, 17-19 May 2010, the report
stated that ?The concept of sustainable development is like a bridge. It seeks to
bring together not only the three domains ? economic, social and environmental
..Development is the midwife of sustainability, just as sustainability is the life
support system for development?.

v. There is now a growing body of evidence to support the principle that the bridge to
sustainable development is through a healthy population which will allow sustained
economic growth, and evidence indicates that well directed investment
designed to improve the health of a population is one of the most cost-effective
means of stimulating gross domestic product (GDP) growth. For example, the WHO
has identified a set of interventions they call ?Best Buys?.

vi. The commonality of the challenges facing the developed/developing countries and
the opportunities for growth through better health make a strong argument for its
inclusion within the Rio+20. Health has a particular value as a unique bridge and
offer an important complement to the orientation of Rio+20 and reinforces its focus
as outlined in Resolution 64/236 which states that the focus of the Conference will
be on ?the following themes of sustainable development and poverty eradication
and the institutional framework for sustainable development".

vii. Most of this burden of disease is preventable, given the will and resources to do so;
the means to address the relevant risk factors is known: what is needed is more
innovation in the application of these means to populations. Improving the health
status of the people worldwide is very largely a challenge to health promotion (which
includes health education, health protection, and disease prevention), and health
inequalities need to be addressed also in the context of improved systems of health promotion. Other policy areas, such as tax, education and transport, are important
for achieving a reduction of risk from lifestyle determinants. . Policy of health
professionals is for instance connected to vertical policies such as labour- and
migration policies, which determine the efficiency of healthcare professionals.
Another important policy area to bring about an efficient healthcare system is
research, which can help develop new instruments, one example being e-Health.
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- EXPECTED OUTCOME 1:

1.1 Inclusion of Health and Health Indicators

i) To meet the aspiration of the G+20, we need to improve the well-being of all
people, so that they can actively participate to the societal and economical

world. There is a need to promote the value of healthcare to the wider economy.
ii) Indicators should be coherent with the aims of the UN Declaration on Non-

Communicable Diseases and the Millennium development Goals.
iii) Objectives should either be seeking to produce outcomes and
recommendations that feed directly into future policy development or be used to
augment the Implementation of health policies.

iv) For example in Europe, three areas of ill-health (cardiovascular diseases,
cancer, and neuropsychiatric disorders) are the cause of 74% of deaths in
Europe, and contribute 54% of the overall disease burden in Europe, as
calculated in Disability Adjusted Life Years (DALYs). The most effective way to
make improvements in these three areas would be to focus on the underlying
determinates of health.

a. there is considerable coincidence between the risk factors for these
conditions which need to be influenced and improved if the disease burden
they create is to be reduced which can be tackled at the international level

i) National control mechanisms should not only depend on agents of horizontal
accountability (the system of checks and balances in the partner country and the
capacity of state institutions to provide oversight and to audit the use of public
resources), but also on mechanisms of vertical accountability (mechanisms
used by citizens and non-state actors such as civil society, nongovernmental
organisations and the media to hold government to account).

ii) Capacity development of NGOs and the media with regard to budget scrutiny
and audit reports should be actively supported by the EC.

iii) Support mechanisms of social accountability such as for instance social audits,
participatory budgeting and citizen report cards to increase the accountability of
government not only to parliament, but most importantly to its citizens.

2: ?HEALTH IS WEALTH?

2.1 Funding

i. Funding from the international community has been widely recognized as crucial if
the world?s poorest countries are to stand any chance to ?safeguard their hard-won
economic gains?. The financing gap was estimated by the IMF in September 2009
for low-income countries in 2009?10 as likely to increase by around US$25 billion a
year. In January, the World Bank?s Chief Economist estimated that poorest
countries that rely on subsidized loans may require an additional $35 billion to $50
billion in funding just to maintain pre-crisis programs.

2.2 Health Expenditure

i. In Europe, health expenditure accounts for nearly 10% of EU Gross Domestic
Product and is one of the biggest economic sectors in the EU. The health sector
employs one in 10 workers in the EU, with a higher than average proportion of
workers with a tertiary level of education and is on the leading edge of innovation
and technology. The sector plays a major role in achieving the EU 2020 targets for
smart, sustainable and inclusive growth.

ii. According to the recent report by the World Economic Forum and the Harvard
School of Public Health: ?Over the next 20 years, NCDs will cost more than US$ 30
trillion, representing 48% of global GDP in 2010, and pushing millions of people
below the poverty line?. Therefore, if no measures are put in place to tackle
NCDs, this estimate cost of US$ 30 trillion will contribute to the overall burden
of poverty on developing countries. As such, there is a growing attention to the
potential economic benefits of improvements in population health. The report by the
WHO Commission on Macroeconomics and Health report in 2001, demonstrated
that health improvement can be seen as a key strategy for income growth and
poverty reduction in low-income and middle-income countries.

iii. This is far from new: historically, one of the origins of the public health movement
lies in the awareness that the prosperity of nations is partly dependent on the health
of their populations.

2.3 Health is Wealth

i. We would emphasize that "Health is Wealth" and point out that by achieving good
health, a developing economy can be more viable and competitive. Health is the
greatest wealth, expresses the understanding that illness is a real economic
cost and good health is a precondition for full productivity. This requires an
active engagement of many policy sectors, not only of the public health and
healthcare systems but also of many other policy areas, including education, social
security, working life, city planning and so forth. Without implementing this action, it
is estimated that ?the period 2011-2030, the total lost output from the four NCD
conditions that are the focus of the UN High-Level meeting and mental health
conditions is projected to be nearly US$ 47 trillion.

2.4 Health in All Policies

i. An integrated approach to health is therefore necessary. We need to ensure that a
health dimension remains in the core of all policies in general, but especially in
innovation and research policy, social policy, regional policy, education policy and
agriculture policy.

ii. Developing synergies with all sectors is crucial for a strong development policy.
Member States of the UN have acknowledged that the challenge of maintaining a
sustainable healthcare system cannot be met without more integration in other
policy areas such as employment, social, regions, agriculture and research including
innovation. Health is very unevenly distributed across society. In all countries,
significant inequalities in health exist between socioeconomic groups in the sense
that people with lower levels of education, occupation and/or income tend to have
systematically higher morbidity and mortality rates.

- EXPECTED OUTCOME 2:

i. Health should be included on the agenda Rio+20 Conference and Agenda. This
should be introduced as a cross-cutting approach so as to avoid ?silo trap?:

ii. Suggest the inclusion of a holistic approach to health and ill-health: from an
increased understanding of what determines health and what determines ill-health,
citizens can be encouraged and supported to lead healthy lives by pursuing the
former and avoiding the latter. This builds resilience and resistance in citizens so
they can remain healthy, resist stressors that could potentially make them unwell
and thus enable them live longer productive and independent lives.

iii. The Rio+20 should support health policies which are based on evidence and
provide a stimulus with which to implement recommendations and policies to
improve citizens health, address entrenched health inequalities, which, as an
outcome, will ultimately lead to sustainable health systems.

iv. To ensure that the IMF deliver its package of measures to assist low-income
countries, and monitor the IMF?s disbursements to those countries, and the
conditionalities attached to them so as to realize health gains

ISSUE 3: CLEAR TARGETS AND INCLUSION OF HEALTH

i. One of the main sources of criticism on the previous meetings was the lack of clear
targets. This allowed the building-up of unsustainable levels of health imbalances that is
destabilising for development and reduces global welfare.

ii. Many of the policy orientations articulated by this forum would have to be implemented
by the relevant international institutions. Effective global economic and financial
governance would, thus, require continuation of intensive reforms in the existing
institutions, and also increased collaboration with NGOs such as patient organisations.

iii. The international community should reaffirm the economic burden that NCD will have
on developing countries as they have done through the UN Declaration on Non-
Communicable Diseases.

- EXPECTED OUTCOME 3:

i. Support a concentrated prioritisation approach. In the past, it was insufficiently
transparent, vested interests are poised to dominate, and there has been duplication of
efforts without proper evaluation. The choices of priority need re-appraisal so as to

ensure that they meet the health need of the citizens.
ii. Programme should support health in all policies which are based on evidence and
provide a stimulus with which to implement recommendations and policies to improve
citizens health, address entrenched health inequalities, which, as an outcome, will
ultimately lead to sustainable health systems.

iii. Including an objective better regulation and harmonization of health development
policy aimed at simplifying and improving existing regulation in order to enhance the
design of new regulations and reinforce rule compliance and effectiveness in line with
the needs of the different peoples

Question 2: What are the comments, if any, on existing proposals: e.g., a green
economy roadmap, framework for action, sustainable development goals, revitalized
global partnership for sustainable development, or others?

ISSUE 1: SUSTAINABLE DEVELOPMENT AND HEALTH

i. Current development policy is based on the principle that the good health of a
population is a precondition for meeting the basic objectives of prosperity, solidarity and
safety. All peoples should have access to universal, quality health care, including
preventive healthcare, and healthcare should be patient-centred and based on scientific
evidence.

ii. To ensure social cohesion, inequalities in health both between and within countries
should be reduced. Because of the multidisciplinary character of health issues, Health
Policy has to be well coordinated with other policies, and new partners such as the
private sector and civic society must be involved.

iii. Additionally, please refer to comments in Q1 as a contribution to the response to this
question.

ISSUE 2: CLIMATE CHANGE:

i. Potential adverse effects of climate change on human health include both direct and
indirect effects. Direct effects concern impacts on the human organism, for example in
consequence of heat waves or extreme weather events.

ii. In particular the elderly and people with a weakened immune system and children are at
risk. High pressure weather conditions in the summer can increase ground-level ozone
causing mucous membrane irritation and respiratory problems. Indirect effects and risks
are caused by environmental changes. These include improved living conditions for
vectors of disease pathogens, the possible geographical extension of allergenic plants
and animals and influences on food and drinking water.

iii. Besides measures addressing health effects of climate change, attention should be paid
to synergies and possible antagonisms between climate change mitigation and air
pollution control so as to prevent diseases such as cancer.

iv. Although successful reductions in the levels of several air pollutants were achieved,
articulate matter and ozone remain a major environment-related health concern, linked
to a loss of life expectancy, acute and chronic respiratory and cardiovascular effects,
impaired lung development in children and reduced birth weight.

ISSUE 3: GREEN ECONOMY

For a green economy, the following policy options are proposed:

i. Provide additional funds for cross-border collaboration across Member States to
improve ambient air quality. Address the synergies, as well as the conflicts, between air
quality management and other policy areas such as climate change mitigation.

Establish a coherent policy framework for indoor air policies and support the
development of worldwide guidance on indoor air quality.

ii. Adopt a systemic approach to chemicals assessment which, besides addressing and
energy use, toxicity and eco-toxicity, should also include material, water a transport,
release of emissions as well as waste generation.

iii. Fill knowledge gaps concerning mixture toxicity and the contribution of chemical
exposure to the total burden of disease especially cancer.

Question 3: What are the views on Implementation and on how to close the
Implementation gap, which relevant actors are envisaged as being involved
(Governments, specific Major Groups, UN system, IFIs, etc.);

In the ?Synthesis report on best practices and lessons learned on the objective and
themes? by the Preparatory Committee for March 7th/8th, it stated that ?Political commitment is
best measured through legislation Factors such as budgetary allocation, development of
institutions and stakeholder participation are strong indicators of political commitment
translated into action. Quantitative indicators (such as budgetary allocation and financial
support) can be effective.?

i. Stakeholder Involvement: Both because smaller and poorer countries will need to be
part of any lasting solution to the global imbalance problem and because corrective
action by systemically significant G-20 members will necessarily impose externalities on
these states, the G-20 quickly needs to find a credible way of bringing these voices into
its deliberations. It could do this either through a constituency based system such as
through the use of a bicameral system where the G-20 could be made accountable to a
body such as the UN General Assembly.

ii. Civil Society Involvement: At the national level, key strategies for increasing patient
empowerment and enabling meaningful patient participation in healthcare and effective
self-care. Such empowerment will be an essential element of future healthcare over the
next 20 years as health is predicted to shift increasingly towards a home and
community environment and towards using eHealth and ICT based solutions for patient-
centred chronic disease management.

iii. Implementing Best Practices from Other Member States: New effective preventive
strategies are currently available that offer the potential to reduce the morbidity and
mortality from this cancer in low- and medium-, as well as high-income countries.
Surveillance, including high-quality cancer registries, linked to screening and
vaccination registries is essential to track the impact of these prevention strategies and
to provide the foundation for advocacy, national policy and global action.

In the Report of the Secretary General, the report stated that ?There is evidence of progress
towards convergence between the economic and social pillars, but evidence of convergence
between those pillars and the environmental pillar is far more limited and the overall picture is
one of divergence; progress to date is also threatened by the series of crises that affected the
global economy starting in 2008?.

i. For the policy area ?resource efficiency?, the following policy options are proposed:

c. Put more focus on how to cover consumer needs in an immaterial way and on
how to provide low-resource consumer services.

d. Develop the ecosystem services concept further and make use of it when
assessing materials, products and processes.

Question 4: What specific cooperation mechanisms, partnership arrangements or other
Implementation tools are envisaged and what is the relevant time frame for the proposed
decisions to be reached and actions to be implemented?

1) Focused Measurable Impacts

If spending programmes are to have any measurable impact, they need to be concentrated on
selected activities that are identified through strategic planning according to a rigorous set of
priorities. The number of priorities should be commensurate with the available budget, as
having too many priorities will reduce the chances of achieving impact in any individual area.

If spending programmes are to have any measurable impact, they need to be concentrated on
selected activities that are identified through strategic planning according to a rigorous set of
priorities. The number of priorities should be commensurate with the available budget, as
having too many priorities will reduce the chances of achieving impact in any individual area.

? Developing sharper priorities that are driven by stakeholder expectations and citizens?
needs as well as meeting policy goals and high standards of probity; monitoring its
activities against not only the aims of each project but also the overall aims of the
programme decision;

? Communicating its priorities and actions more crisply to stakeholders, and targeting
tailored messages to members of the wider public health community.

? Understanding what is required to deliver this would be facilitated by developing a logic
model capable of tracing the precise causal relationships that are anticipated to
connect the programme activities to its intended outcomes.?

2) Possible approaches to ensure Implementation

i. education of health and finance ministers of countries on the association between
healthy populations and GDP growth, on the main health challenges in preventing such
good health, and on potential actions within countries, needed to remedy these;

ii. financial incentives by international community,

iii. involving the inactive countries in the design of the call for projects, the call for projects.
Their participation will ensure that projects will meet health needs in their country, thusincreasing the possibility that local stakeholders will apply for projects;

iv. assisting countries not involved to develop relevant capacity (especially public health
capacity) where serious capacity deficiencies are identified; and specifically targeted
towards low-GDP countries (for example leadership development in health, or change
management courses) could increase the number of participants from low-GDP
countries and awareness of the Programme and its activities.

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v. organising high-level conferences or technical consultations about Health topics in
countries with low participation levels as an instrument to deliver impulses and mobilise
country representatives

vi. tackling language barriers which occur in the comprehension of terminology and
applying it in the national context;

vii. more involvement of essential stakeholders in countries, e.g. a special initiative to
educate and to collaborate with academic institutions and civil society representatives in
MS, at which worldwide plans and priorities could be publicised;